A case of attempted transbronchial spigot insertion for fistulous pyothorax in the residual pleural airspace after pleurectomy/decortication for malignant pleural mesothelioma

Our plain-English summary of A case of attempted transbronchial spigot insertion for fistulous pyothorax in the residual pleural airspace after pleurectomy/decortication for malignant pleural mesothelioma, by R. Miyata, S. Morizono, T. Umehara, et al (Respirology Case Reports, 2024).

The study

• Authors: R. Miyata, S. Morizono, T. Umehara, A. Harada-Takeda, G. Kamimura, M. Aoki, T. Nagata, K. Ueda
• Journal: Respirology Case Reports
• Published: 2024;12(1):e01286
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Pleurectomy/decortication for malignant pleural mesothelioma is a relatively recent surgical approach for which there is a dearth of information on complications, especially in the late postoperative period. A 70-year-old man was diagnosed with right epithelioid malignant pleural mesothelioma and underwent pleurectomy/decortication. Computed tomography at 6 months after surgery revealed nodules on the surface of the right lung. These nodules gradually increased in size and were diagnosed as recurrent disease. Immunotherapy was started, but treatment was discontinued a few days after the first course due to pneumonitis. Subsequent oral prednisolone therapy for about 2 months ameliorated pneumonitis, but fistulous pyothorax developed. During attempted transbronchial occlusion of the responsible bronchus, some spigots penetrated the empyema cavity. Open window thoracotomy was performed on the following day. This case suggests that if there is no change in diameter between the proximal and distal parts of the responsible bronchus, transbronchial occlusion should not be chosen.

© 2024 The Authors. Respirology Case Reports published by John Wiley & Sons Australia, Ltd on behalf of The Asian Pacific Society of Respirology.

In plain English

This case report described a 70-year-old man with right epithelioid malignant pleural mesothelioma. The article did not describe any asbestos exposure for him. He had 2 courses of cisplatin and pemetrexed, then pleurectomy/decortication surgery. Prolonged air leakage followed surgery, and an air space persisted in the right chest. Nodules seen on CT at 6 months gradually grew and were diagnosed as recurrence. Nivolumab plus ipilimumab, started at 10 months, was stopped a few days after the first course because of grade 2 pneumonitis (lung inflammation), treated with prednisolone. By 12 months the air space had enlarged with a little fluid; about 3 weeks later, drainage showed air leakage and pus, diagnosed as fistulous pyothorax. Blocking the responsible right middle lobe airway with silicone plugs (endobronchial spigots) failed when a spigot penetrated the infected cavity. Open window thoracotomy followed the next day; he left hospital on postoperative day 24. The airway measured 3.5 mm at both ends, and the authors hypothesised that an earlier spigot was pushed toward the cavity by inserting another. The authors concluded that spigots should be avoided when the airway does not narrow toward its far end.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One 70-year-old man with right epithelioid malignant pleural mesothelioma
• Exposure: The article does not report the patient's asbestos exposure. The case concerns complications of surgical and endoscopic treatment.
• Main results:
  • The patient received 2 courses of cisplatin and pemetrexed before right pleurectomy/decortication. After prolonged air leakage, the chest tube was removed on postoperative day 16.
  • A residual air space persisted in the right chest throughout follow-up
  • Nodules on the right lung surface were noted on CT at 6 months after surgery. They gradually increased in size and were then diagnosed as recurrence of mesothelioma.
  • Nivolumab plus ipilimumab was started at 10 months. It was stopped a few days after the first course because of grade 2 pneumonitis, and 30 mg/day oral prednisolone was given.
  • At 12 months after surgery, CT showed an enlarged residual air space with a small amount of fluid. The patient had no symptoms at that time.
  • About 3 weeks later, coughing appeared and a chest X-ray showed an air-fluid level
  • After thoracic drainage, air leakage and purulent fluid were observed, leading to a diagnosis of fistulous pyothorax. The responsible bronchus was in the right middle lobe.
  • During bronchial blockage with an endobronchial spigot, a spigot penetrated into the empyema cavity, and transbronchial occlusion was judged not possible
  • Open window thoracotomy was performed the next day. The course was uneventful and the patient was discharged on postoperative day 24.
  • The responsible bronchus measured 3.5 mm both proximally and distally. The authors hypothesised that an earlier spigot was pushed toward the distal bronchus and pleural cavity by insertion of another spigot.
• The authors' conclusion: The authors concluded that if the responsible bronchus does not taper in diameter between its proximal and distal parts, transbronchial occlusion with spigots should be avoided

Topics

Medical terms in this study, explained in our Lexicon: Empyema, Pleurectomy/Decortication (P/D), Pleural Mesothelioma, Epithelioid, Immunotherapy, Pneumonitis, Bronchus, Thoracotomy.

Related studies

• A Clinical Trial of TumorGlow to Identify Residual Disease During Pleurectomy and Decortication — J.D. Predina, A.D. Newton, et al. (2019)
• Thoracic shaping technique to avoid residual space after extended pleurectomy/decortication — S. Bölükbas, M. Eberlein, et al. (2013)
• Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma — E. Taioli, A.S. Wolf, et al. (2015)
• A phase II trial of pleurectomy/decortication followed by intrapleural and systemic chemotherapy for malignant pleural mesothelioma — V. Rusch, L. Saltz, et al. (1994)
• Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma — L. Lang-Lazdunski, A. Bille, et al. (2012)
• Extended Pleurectomy-Decortication-Based Treatment for Advanced Stage Epithelial Mesothelioma Yielding a Median Survival of Nearly Three Years — J.S. Friedberg, C.B. Simone, et al. (2017)

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